Elkhart Central Boys Basketball
Elkhart Central Boys Basketball Girls & Boys - Grades 2-8
Basketball Appreciation Camp August 3, 2017 6:00pm – 8:00pm North Side Gym Cost: $8.00 per camper *bring your own ball (Make Checks payable to ECHSAA – BBB) WE ALSO DO PRIVATE LESSONS - Contact Coach Smith Contact Terry Smith, Boys Head Coach Please email Coach Smith to
517-897-6574 or [email protected] confirm reservation: Meet Blazer Coach Smith
& High School Players!
Terry Smith, Boys Head Coach
517-897-6574 or [email protected]
---------------------------------------------------------------------Sign and return this form along with payment to: Elkhart Central Athletics Attn. Coach Terry Smith 1 Blazer Blvd. Elkhart, IN 46516
Name: __________________________________________________ Age: ___________ Grade: __________ (2017-18) School: ___________________________ Phone: ____________________________ Address: ___________________________________________________City: ______________ Zip: __________ Please list any medical condition, including allergies that camp personnel should be aware of: ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ List any medications the child is currently taking: ________________________________________________________________________ As Parent/legal guardian of the participant named above, I authorize Elkhart Central Camp Personnel to seek medical &/or surgical treatment which is reasonably necessary to care for the participant. I further authorize the medical facility that treats participant to release all information needed to complete insurance claims. I acknowledge my responsibility to pay all costs associated with the participant’s medical care & authorize medical payments, if any, to be made directly to the medical facility. I understand that basketball is a contact sport & one in which physical injury can occur, including serious & potentially permanent injury or even death. In exchange for the coaching & training in this sport, we agree to hold Terry Smith harmless; defend & indemnify him from any & all claims, demands, costs, expenses, & fees, including actual attorney fees, made against him or advance/incurred by him arising from, or in any way connected to him providing basketball &/or physical conditioning & training to my child.
Emergency contact: ________________________________________ Phone: ____________________________________________ Parent Signature: ___________________________________________________________Date: ___________________________
Basketball Appreciation Camp August 3, 2017 6:00pm – 8:00pm North Side Gym Cost: $8.00 per camper *bring your own ball (Make Checks payable to ECHSAA – BBB) WE ALSO DO PRIVATE LESSONS - Contact Coach Smith Contact Terry Smith, Boys Head Coach Please email Coach Smith to
517-897-6574 or [email protected] confirm reservation: Meet Blazer Coach Smith
& High School Players!
Terry Smith, Boys Head Coach
517-897-6574 or [email protected]
---------------------------------------------------------------------Sign and return this form along with payment to: Elkhart Central Athletics Attn. Coach Terry Smith 1 Blazer Blvd. Elkhart, IN 46516
Name: __________________________________________________ Age: ___________ Grade: __________ (2017-18) School: ___________________________ Phone: ____________________________ Address: ___________________________________________________City: ______________ Zip: __________ Please list any medical condition, including allergies that camp personnel should be aware of: ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ List any medications the child is currently taking: ________________________________________________________________________ As Parent/legal guardian of the participant named above, I authorize Elkhart Central Camp Personnel to seek medical &/or surgical treatment which is reasonably necessary to care for the participant. I further authorize the medical facility that treats participant to release all information needed to complete insurance claims. I acknowledge my responsibility to pay all costs associated with the participant’s medical care & authorize medical payments, if any, to be made directly to the medical facility. I understand that basketball is a contact sport & one in which physical injury can occur, including serious & potentially permanent injury or even death. In exchange for the coaching & training in this sport, we agree to hold Terry Smith harmless; defend & indemnify him from any & all claims, demands, costs, expenses, & fees, including actual attorney fees, made against him or advance/incurred by him arising from, or in any way connected to him providing basketball &/or physical conditioning & training to my child.
Emergency contact: ________________________________________ Phone: ____________________________________________ Parent Signature: ___________________________________________________________Date: ___________________________
